In This Issue
Spring, 2003
Volume 6, Issue 1
SPRING 2015
HPSJ website and DRE: Help for Your Practice
As 98% of HPSJ providers already know, our website’s DRE
(Doctors’ Referral Express) provider portal is essential to the smooth
running of both the care and business sides of practices.
For a complete list of online provider functions, see page 2.
Log on to www.hpsj.com and click the
p 2 - HPSJ.com Topics
p 3 - When super-doses of opioids aren’t enough
- False Claims Act
p 4 - Survey Results are in: The Patient
Experience
p 5 - Treatment: Autism
- HEDIS: Thanks for
Contributing
p 6 - Missed Appointments
Providers icon to:
8
8Check patient eligibility
8Access provider searches
8Search the formulary and latest updates
your transition to ICD-10 coding
8Support
(October 1, 2015 transition)
Submit authorizations or check the status
- HPSJ Formulary
p 7 - Chronic Insomnia
p 8 - Behavioral Health
Services
Coming Up: 2015 DMHC / DHCS Joint Audit
As part of an ongoing series of health plan audits, California’s Department of Managed Health
Care (DMHC) and the Department of Health Care Services (DHCS) have scheduled a joint audit
of Health Plan of San Joaquin. Auditors will be onsite at HPSJ from July 13 throughout July 24.
During this time, DHCS staff will also conduct interviews with HPSJ providers at their practice
locations. If you are chosen HPSJ will call you to schedule an interview time with DHCS.
If you have questions, please contact HPSJ Provider Services at 209.942.6340.
Look for these
coming Alerts:
•Changes to CMS 1500 billings for June 1, 2015
•Good News: HPSJ will be paying for each immunization, not just one flat fee for all children’s shots
New leader for HPSJ governing board adds
to already strong provider expertise
Greg A. Diederich
Greg A. Diederich is
spent seven years at Stanislaus County Health
the new chair of the
Services Agency where he was associate
San Joaquin Health
director for clinical services. While there, many
Commission, HPSJ’s
at HPSJ had the pleasure of working with
11-member governing
him as we expanded the Medi-Cal program
board, as of January 14.
in Stanislaus County. In addition to being
January 5 was his first day
well-informed about that region of the HPSJ
on the job as Director of
geographic service area, Greg Diederich has
the San Joaquin County
a deep understanding of the current health
Health Services Agency,
care landscape and he adds to the already
and as an ex officio member
considerable provider expertise contributed
of the San Joaquin Health Commission. With
by current San Joaquin Health Commission
over 19 years in private and public sectors
members Drs. Marvin H. Primack, Gentry Vu,
of the health care industry, he most recently
Mohsen Saadat, and Michael Herrera.
FRENCH CAMP
7751 S. Manthey Rd.
French Camp
MODESTO
1012 10th Street,
Modesto
1•888•936•PLAN (7526)
www.hpsj.com
Provider Services
209•942•6340
Hearing Impaired
(TTY/TDD) 209•942•6306
Topics of Interest to Providers on www.hpsj.com
We include information about many topics of interest on
our website. You can view and/or download information
about the following topics at www.hpsj.com.
n Information about HPSJ’s Quality Improvement Program
including goals, processes and outcomes as related to
care and service.
n The process for practitioners, facility staff, including
discharge planners, to refer members to case
management.
n The process to refer members to disease management.
n Information about disease management programs,
including how to use the services and how HPSJ works
with a practitioner’s patients in the program.
n Information about how to obtain or view copies of
HPSJ’s specific adopted clinical practice guidelines and
preventive health guidelines, including those for:
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n The toll-free number to contact staff regarding UM issues
n The availability of TDD/TTY services for members
n Information about how members may obtain language
assistance to discuss UM issues
n HPSJ’s policy prohibiting financial incentives for utilization
management decision-makers
n Information about HPSJ’s pharmaceutical management
procedures including: our drug list along with restrictions
and preferences; how to use pharmaceutical
management procedures; an explanation of limits and
quotas; how practitioners can provide information to
support an exception request; and HPSJ’s processes for
generic substitution, therapeutic interchange, and
step-therapy
n A description of the process to review information
submitted to support a practitioner’s credentialing
application, correct erroneous information and, upon
request, to be informed of the status of the credentialing
or re-credentialing application
Clinical Practice Guidelines:
• Attention deficit hyperactivity disorder (ADHD)
• Asthma
n HPSJ’s member rights and responsibilities statement.
• Chronic Obstructive Lung Disease (COPD)
• Depression
• Diabetes
If you have any questions about
• Heart Failure
Preventative Health Guidelines:
accessing our website or need
• Pediatrics (ages 0-18 years), Preventative Pediatric more information, please call the
Health Care
• Pediatrics (ages 0-18 years), Immunization Provider Services Department at
Recommendations for ages 0-18 Perinatal
209•942•6340.
• Adults (ages 19-64 years), Preventative Care •Geriatrics (ages 65+); Fall precautions for ages Most recent information
65-older
about this is always available
• Information about HPSJ’s medical necessity on our website.
criteria, including how to obtain or view a copy
Information about the availability of staff to answer questions about Utilization Management (UM) issues
When super-doses of opioids still aren’t “enough”
Opioid-Induced Hyperalgesia (OIH) is a condition where the
administration of opioid analgesics actually causes the patient
to become more sensitive to (and experience pain from)
non-painful stimuli. OIH is difficult to diagnose as its symptoms
are often mistaken for signs of opioid tolerance. It was not until
recent years that OIH was recognized by health professionals as
a clinically relevant occurrence.
OIH symptoms:
• Loss of opioid efficacy despite dose escalation
without disease progression
• Increasingly diffuse pain
• Progressive pain that feels “worse than before”
experienced as a result of OIH is often more severe and painful
Etiology
While the exact cause of OIH is still unknown, there is evidence
that NMDA receptors are mainly responsible for OIH. Glutamate
is an excitatory neurotransmitter that binds to NMDA receptors.
When glutamate is bound, NMDA receptors increase spinal
sensitization making the patient more sensitive to pain. Current
research is investigating to see if NMDA receptor antagonist is
the answer to OIH.
than the original onset of pain.
Managing OIH
If OIH is suspected, slowly taper down the opioid regimen to
avoid opioid withdrawal effects and educate the patient
that pain relief from opioid dose reduction or discontinuation
is not immediate. Opioid rotation or combination is not
recommended as there is insufficient evidence to support
Differentiating OIH from Opioid Tolerance in the early stages,
OIH resembles opioid tolerance. A patient may continue to
complain of pain and the prescriber may increase analgesic
dose. However, for a patient experiencing opioid tolerance,
an increase in opioid dose will relieve pain whereas a dose
increase for a patient with OIH will worsen pain. Furthermore,
tolerance develops slowly (over 2 to 3 months) whereas OIH
its clinical efficacy. There is some evidence that gabapentin
can increase pain threshold and reduce OIH symptoms.
The addition of certain antiepileptic agents or serotoninnorepineprhine reuptake inhibitors (i.e. venlafaxine) may
increase pain tolerance and be beneficial.
This article contributed by Brenda Ng, HPSJ Pharmacy Resident.
has a more immediate response to the dose increase. The pain
Bottemiller S. Opioid-Induced Hyperalgesia: an emerging treatment challenge. US Pharm. 2012; 37(5):HS-2HS-7. DuPen A, Shen D, and Ersek M.
Mechanisms of opioid-induced tolerance and hyperalgesia. Pain Management Nursing. 2007; 8(3): 113-121. Mao J, Sung B, Ru-Rong J, et al.
Neuronal apoptosis associated with morphine tolerance: Evidence for an opioid-induced neurotoxic mechanism. Journal of Neuroscience. 2002;
22:7650-7661. Compton P, Kehoe P, Sinha K, et al. Gabapentin improves cold-pressor pain responses in methadone-maintained patients. Drug
Alcohol Dependence. 2010; 109: 210-219.
False Claims Act
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The False Claims Act imposes liability on any person who submits
or regulatory requirements. The third area of liability includes
a claim to the federal government that he or she knows (or
those instances in which someone may obtain money from
should know) is false. An example may be a physician who
the federal government to which he may not be entitled and
submits a bill to Medicare for medical services she knows
then uses false statements or records in order to retain the
she has not provided. The False Claims Act also imposes
money. An example of this so-called “reverse false claim” may
liability on an individual who may knowingly submit are false
include a hospital that obtains interim payments from Medicare
record in order to obtain payment from the government. An
throughout the year, and then knowingly files a false cost report
example of this may include a government contractor who
at the end of the year in order to avoid making a refund to the
submits records that he knows (or should know) is false and
Medicare program.
that wrongly indicate compliance with certain contractual
3
Measuring the patient experience - how are we doing?
Like you, and all of our providers, HPSJ believes that a high quality
customer experience is essential for the health and well-being of
every patient. The California Department of Health Care Services
(DHCS) agrees with us. That is why every two years DHCS assesses
the perceptions and experiences of HPSJ’s Medi-Cal program
beneficiaries, hiring an independent contractor to survey a sample
of adult and child members about their customer experiences,
perceptions, satisfaction, and practice loyalty.
Results are now in for the 2013 Consumer Assessment of Healthcare
Providers and Systems (CAHPS) conducted by Health Services
Advisory Group. While these results paint a broad-brush picture and
do not apply in all situations for all doctors, they do give us a window
into the perceptions of a preponderance of surveyed patients.
During this era of extraordinary health care change – with providers
on the front lines of patient access, ever-shorter appointments,
and growing technology/regulatory requirements – we pass along
some survey takeaways that we hope have value as you and your
hardworking practice are continually endeavoring to offer the very
best in the science and art of medicine.
Rating of Personal Doctor
• Their personal doctor did not always spend enough time with them.
• Others reported that their personal doctor did not always seem informed and up-to-date about the care their child received
from other doctors or health providers.
Rating of All Health Care
• When they talked about starting or stopping a prescription medicine, a doctor or other health care provider did not ask what they thought was best for them, or they did not talk about the reason the patient might not want to take a medicine.
• Their personal doctor did not always spend enough time with them.
• Their personal doctor did not always seem informed and up-to-
date about the care their child received from other doctors or health providers.
Getting Care Quickly
4
• Respondents report that when they did not need care right
away, they did not obtain an appointment for health care as
soon as they thought they needed.
Connect with Your Patients:
TOP TIPS from Latest Research
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Think about what you want to say, then translate it
into lay-person’s language.
Avoid distractions so that patients feel they are
important. Giving undivided attention in the first
60 seconds can “create the impression that a
meaningful amount of time was spent with them.”
8
Perception of time. Older patients take in less
information than younger patients, but they desire
more information from their physicians. Older patients
are going to require more time.
8
Face-to-face. Patient compliance with treatment
recommendations is greater after encounters where
physician and patient are face-to-face.
8
Eye contact, it creates a more positive, comfortable
atmosphere that may result in patients opening up
and providing additional germane information.
8
Listen. Not doing so is the most common complaint
patients have about their doctors.
8
Speak slowly, clearly and loudly enough so patients
can take in, learn and commit to memory information
and instructions.
8
Make sure the patient understands – ask them to
repeat what has been said. By listening to what
they’ve processed, providers are able to see,
immediately, what they do not understand and they
can go back over what has been missed.
8
Remind patients to call and cancel or reschedule
if unable to make appointment.
Share your tips for connecting to patients.
Contact our Provider Services Department
at 209•942•6340.
Treatment for Autism
As of September 15, 2014, Medi-Cal plans are
in charge of supplying Behavioral Health
Therapy (BHT) services to those under the age of
21 who have an Autism Spectrum Disorder (ASD)
diagnosis. Health Plan of San Joaquin’s
Behavioral Health Benefits Manager, Beacon
Health Strategies manages this benefit for
beneficiaries. Department of Health Care
Services is now defining the continued care
process for members being followed by
the Regional Centers. Contact Beacon at:
855•371•3938.
See page 8 for more from Beacon.
Thanks for Contributing to HEDIS TIME for HPSJ
HEDIS is –
The Healthcare Effectiveness Data and
Information Set (HEDIS) remains the
most widely used set of performance
During spring of each year, HPSJ works with our contracted providers to
review encounter and claims data from the prior year and conducts medical record reviews to survey “how well your practice” completes certain
services. These services include:
measures in the United States health
care delivery system. HEDIS was
developed and is maintained by
the National Committee for Quality
Assurance (NCQA). The performance
measures in HEDIS are related to many
significant public health issues such
as cancer, heart disease, smoking,
well child
visits
timely
prenatal
and
immunizations
postpartum
visits
cholesterol
management
and diabetes. The State of California
cervical
cancer
screenings
diabetic
care
adult BMI
controlling
high blood
pressure
weight
assessment/
counseling
Department of Healthcare Services
(DHCS) uses the HEDIS measures to
evaluate health issues and health plan
performance. HEDIS measures the
quality and effectiveness of care and
provides a method of scoring so that
HPSJ can incentivize our providers for
their efforts in delivering the highest
quality of preventive and effective
care.
Medical Record Review:
HEDIS review. HPSJ’s goal continues to be
Traditionally scheduled for February through
making this process as efficient as possible.
May of each year, the 2015 Medical Record
Thank you for contributing to another
Review process has now been completed.
successful HEDIS season! We look forward
NCQA requires HPSJ to review the above
to reporting back to you with HEDIS results
components in your HPSJ patient’s medical
in an upcoming PlanScan issue. Meanwhile,
records. We at HPSJ very much appreciate
please contact our Provider Services
all the efforts of your practice to pull the
Department at 209•942•6340 with any
minimum number of charts required for
questions.
5
Best Practices & HPSJ Help: Handling No-Shows
Missed appointments are more than an annoyance. We’ve
been hearing from HPSJ provider practices that this is a growing
problem and one that can disrupt already busy appointment
rosters whenever a patient – for whatever reason – does not
appear at the scheduled time, or cancels at the last minute.
So that we can educate members who may have done this two
or three times, please call our Customer Service Department
at 1•888•936•PLAN (7526). It would be most productive to get
timely information from your office including the following:
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2
3
4
5
6
7
8
Member name & Member ID number
Date of the missed scheduled
appointment
Was this a last minute cancellation?
Or, was it an unexplained missed
appointment?
How many times (total) has this
happened?
Did the member provide any
information as to why they did
not appear?
Does your practice employ a reminder
system via – postcard? phone call?
digital messaging?
Are the appointment reminders in any
languages other than English?
Meanwhile, there are valuable HPSJ resources for your patients
who are our members. Neither language nor lack of adequate
transit sever be a barrier to the health and well-being of your
patients.
Interpreter Services:
• Translators are available for Limited English Proficient (LEP) patients and for those who are hearing impaired
• These services are for all points of member contact – including the member’s time in your office.
• They are FREE, and available 24 hours a day
• To find out more, call our Customer Service Department at 1•888•936•PLAN (7526)
Transit to a scheduled appointment:
• Bus system vouchers, two per appointment (transfers not covered); members must call our Customer Service Department at 1•888•936•PLAN (7526) 10 business days in advance of the appointment so that the vouchers can be processed and the member can receive them in time
• HPSJ can provide alternative medical ground transportation for scheduled appointments when it is not medically advisable for patients to use a public or private vehicle; HPSJ and the member’s PCP must approve this request before the appointment takes place; our Customer Service Department can walk the member through the process to see if this is possible.
Please encourage
members
to contact our
Customer Service
Department and
schedule interpreter or
transit services as soon
as the member has
confirmation of their
next appointment.
Both types of services
should be canceled 24
hours in advance if an
appointment is
canceled or
rescheduled.
Contact Our Customer Service Department,
Monday – Friday from 8:00 am – 7:00 pm
1•888•936•PLAN (7526)
Hearing Impaired call TDD/TYY:
209•942•6306
The HPSJ formulary is available at www.hpsj.com
The HPSJ Formulary and the most recent changes from the quarterly Pharmacy & Therapeutics (P&T)
Committee meetings are available at www.hpsj.com in the Provider section. A printed formulary is available
upon request. Formulary management procedures and exception request instructions are available online in
the Provider Manual. Changes to the formulary management procedures are also available online.
Formulary Addition Request Forms
6
To request that the P&T Committee consider additions to the HPSJ Formulary, you can file a one-page form,
located online in the HPSJ Provider Manual (Section 2, Page 3) or call Provider Services at 209•942•6340.
Chronic Insomnia: Prescribing the
Most Effective Therapy for Sleep
Drug Class
Drug Name
Alcohol
Alcohol
Antidepressants
(SNRIs/ some SSRIs)
Fluoxetine, paroxetine, sertraline (stimulating/sedating), bupropion,
venlafaxine, duloxetine, desvenlafaxine
Decongestants
Pseudoephedrine, phenylephrine
Diuretics
All diuretics
Pulmonary
Albuterol, levoalbuterol, theophylline
Stimulants
Caffeine, methylphenidate, amphetamine, modafinil
By Brenda Ng, PharmD
According to the National Sleep Foundation, insomnia
affects 33% of American adults. “Insomnia” is defined by
the Journal of Clinical Sleep Medicine as: “difficulty with
sleep initiation, duration, consolidation…and that result in
some form of daytime impairment.” There are many factors
(social, psychological, physical health) that can lead to sleep
deprivation, including medications.
Treatment Recommendations
As recommended by the American Academy of Sleep
Medicine, the gold standard to the management of chronic
insomnia is behavioral therapy, unless the individual has an
underlining psychological disorder.
Behavior therapy may include single or combination of lifestyle
modifications, relaxation techniques, light therapy, or sleep
restriction. Pharmacological therapy or sleep aids may be used
short-term (2-4 weeks) to improve sleep quality while behavioral
therapy is initiated. All sleep aids cause day-time drowsiness
and diminish in efficacy overtime. They should not be used
chronically due to concerns with safety and drug tolerance or
dependence issues.
Formulary Sleep Aids and Treatment Algorithm 2
First Line Therapy: Use sedative hypnotics or benzodiazepines
Sedative Hypnotics: Specifically target the benzodiazepine 1
(BZ1); associated with infrequent cases of amnesia and sleep
walking.
• Zaleplon is short-acting and primarily used for
sleep induction.
• Zolpidem is short-to intermediate-acting and can be used for either sleep induction or sleep maintenance.
• Benzodiazepines: Mechanism: Binds to GABA
receptors to enhance its CNS inhibitory effects;
increased risk of falling in elderly.
• Clonazepam, alprazolam are not used for insomnia due to very short duration of action.
• Temazepam has the longest duration of action and useful for sleep maintenance.
• Lorazepam has a shorter duration of action than
temazepam, but is faster-acting and may be useful for sleep induction.
Second Line Therapy: If the first line therapy is ineffective, try a
different first line therapy
Third Line Therapy: Try a low dose sedative antidepressant.
• Sedative antidepressants (i.e., trazodone, mirtazapine, amitriptyline): blocks histamine-1 receptors leading to drowsiness.
• May be useful for patients with concomitant depression and/or mood disorders with insomnia.
• Mirtazapine is also used for appetite stimulation.
Fourth Line Therapy: Combination of sedative hypnotics/
benzodiazepines and low dose sedating antidepressants.
7
7751 South Manthey Road
French Camp, CA 95231
Behavioral Health Services for HPSJ Members
Beacon Health Strategies
855•765•9703
www.beaconhealthstrategies.com
Beacon, our new contracted vendor for behavioral health
services, covers individual and group therapy, psychiatric
consultation and psychological testing for HPSJ Medi-Cal
members with mild-to-moderate impairments. Members do
not need a PCP referral to access behavioral health services,
but must undergo a brief telephonic screening to ensure their
condition is mild-to-moderate. If the member’s condition is
severe, Beacon will assist in transitioning the member to the
county’s mental health services for care.
Emergency and acute services, such as hospital care, crisis
With one call to Beacon you can:
response, and rehabilitation programs continue to be provided
• Get information on covered behavioral health services
by the county’s behavioral health services.
• Locate behavioral health providers
• Get help making a routine or urgent appointment
When you call Beacon, let us know that you are a PCP or
• Check a member‘s benefits and eligibility
that you’re calling on behalf of a PCP. Our staff will help you
• Get decision support related to prescribing psychiatric
immediately or connect you with a clinician if necessary. If
medications from a Beacon psychiatric advisor
you call outside of business hours, you will be automatically
• Request support coordinating a member’s care
transferred to our clinical service team for urgent concerns.
• Learn about behavioral health care and substance use
treatment services offered by the County Department of Behavioral Health Care Services.